The Coroners Court hearing in Ballarat in February heard Mr Ross, 65, intended to have a routine echocardiogram at the hospital on October 28, 2009, in order to see his cardiologist in a few weeks’ time. Instead, doctors stayed back late to perform an urgent CT-guided procedure to investigate and drain fluid from around his heart.

Referring to the procedure in her finding, Ms Heffey said it had been unsuccessful, with no fluid drained into the cannula of the needle.

“Shortly after the needle had been withdrawn, Mr Ross complained of feeling strange and went into cardiac arrest,” Ms Heffey said.

“In the course of the resuscitation effort, an attempt was made to drain the pericardium. It would seem that in the course of this, the mycocardium was penetrated and blood flowed into the pericardial sac,” Ms Heffey said. “I consider that the cardiac arrest was a result of a perforation of the right ventricle in the course of therapeutic pericardial drainage leading to cardiac tamponade.”

The coroner noted Mr Ross had had his left lung removed due to lung cancer, in turn distorting his anatomy and shifting his heart into a different position. The coroner made no formal recommendations in her finding.